Treatment of Tonsil Stones
Start with conservative management including adequate hydration and honey as adjunctive therapy, reserving surgical intervention (tonsillectomy or coblation cryptolysis) only for patients with recurrent infections meeting Paradise criteria or those with symptomatic large stones that fail conservative measures. 1, 2
Conservative Management (First-Line)
- Adequate fluid intake is the cornerstone of initial therapy, helping naturally flush debris from tonsillar crypts and providing relief from discomfort. 1, 2
- Honey should be used as adjunctive therapy due to its antimicrobial properties and throat-soothing effects. 1, 2
- Ice popsicles/lollies can provide temporary symptomatic relief. 2
- Most small tonsilloliths are common clinical findings that can be managed expectantly, as they often pass spontaneously. 3
When to Consider Surgical Intervention
Tonsillectomy should be considered only when patients meet Paradise criteria for recurrent infections:
- ≥7 episodes of tonsillitis in the past year, OR 1
- ≥5 episodes per year for 2 consecutive years, OR 1
- ≥3 episodes per year for 3 consecutive years 1
Modifying factors that lower the threshold for surgery include:
- Multiple antibiotic allergies or intolerance 1
- History of peritonsillar abscess 1
- Large stones that cannot pass spontaneously (rare cases requiring surgical removal) 4, 3
A 12-month observation period is recommended before proceeding with tonsillectomy, as spontaneous improvement occurs in many cases. 1
Surgical Options
For patients requiring intervention:
- Coblation tonsil cryptolysis can be performed in adults under local anesthesia without sedation, with pain significant for only a few days and normal activity resumption within 1 week. 5
- This technique achieves significant decrease or elimination of tonsil stones after a single session, avoiding the morbidity of complete tonsillectomy. 5
- Complete tonsillectomy remains an option for patients meeting Paradise criteria, using techniques including electrocautery, coblation, or cold dissection. 1
- Laser tonsillotomy is not considered complete tonsillectomy and has higher recurrence rates. 1
Perioperative Pain Management (If Surgery Required)
Multimodal analgesia is mandatory:
- Scheduled paracetamol (acetaminophen) started pre/intra-operatively and continued postoperatively 1, 6
- NSAIDs (ibuprofen) combined with paracetamol unless contraindicated, providing superior analgesia 1, 6
- Single intraoperative dose of IV dexamethasone for analgesic and anti-emetic effects 1, 6
- Opioids reserved only as rescue medication when other measures are insufficient 1, 6
- Codeine should be avoided in children younger than 12 years 1
Important caveat: Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent meta-analyses. 2, 6
Critical Monitoring Points
- Monitor for adequate pain control after any procedure to prevent poor oral intake and dehydration. 1, 6
- Tonsillectomy carries risks including bleeding, pain, dehydration, and rarely more serious complications. 1
- Enhanced patient education and telephone follow-up improve compliance with analgesic regimens. 6
What NOT to Do
- Do not routinely prescribe perioperative antibiotics for tonsillectomy. 1
- Do not restrict diet to liquids or cold foods only—encourage adequate hydration and nutrition as tolerated. 6
- Do not proceed with tonsillectomy without meeting Paradise criteria or completing the recommended 12-month observation period. 1